Optometry Intake and Consent Form

Optometry Intake and Consent Form
Patient Information
*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Date of last eye exam

MonthDayYear
Date
What is the reason for your visit today?

Routine Eye ExamVision ProblemsVision Problems Using the Computer or ReadingScreening or Eye DiseasePrescription for GlassesOther
Do you experience any of the following symptoms? (Please check all that apply)

Blurred VisionLight SensitivityEye StrainDry EyesEye Pain or DiscomfortItchy EyesHeadachesOther
Do you have any of the following conditions? (Please check all that apply)

DiabetesHypertensionGlaucomaCataractsRetinal DisordersAsthmaHeart DiseaseMacular DegenerationOther
Are you currently taking any medications?

YesNo
If yes, please list the medications you are taking.
Are you currently wearing glasses or contact lenses?

GlassesContact LensesNeither
When did you start to wear your current glasses?
Are your glasses For?

Far DistanceNear DistanceBoth Far & Near
Have you been diagnosed with medical conditions that can affect eyesight, such as:

DiabetesHypertensionOther
Have you been diagnosed with conditions specific to the eyes, such as:

GlaucomaCataractsOther
Do you have a personal history of eye surgeries and/or treatments?

NoYes
If yes, please specify.
Is there a Known family history of eye disease?

NoYes
If yes, please specify.
Do you have any allergies to medications?

YesNo
If yes, please list what allergies.
Have you had any previous eye surgeries or treatments?

YesNo
If yes, please describe.
Does anyone in your family have a history of the following? (Please check all that apply)

DiabetesHypertensionGlaucomaCataractsRetinal DisordersAsthmaHeart DiseaseMacular DegenerationOther
How many hours per day do you spend using digital screens (computer, phone, etc.)?
Are you exposed to high levels of sunlight or UV radiation frequently?

YesNo
Do you drive at night frequently?

YesNo
Do you experience any of the following? (please check all that apply)

Double VisionLight SensitivityEye StrainDry EyesHeadachesNone of the Above
Which of these apply to you? (Please check all that apply)

SmokeDriverDrink AlcoholPregnant
Consent for Optometry Services
I, the undersigned, consent to the optometric services to be provided by the healthcare professionals at KCS. These services may include:
- Comprehensive eye examination
- Prescription of corrective lenses (glasses or contact lenses)
- Screening and management of eye diseases such as glaucoma, cataracts, and diabetic retinopathy
- Dilation of pupils for better examination of the internal structures of the eyes
- Referrals to ophthalmologists or other specialists if necessary
Disclosure of Risks and Benefits

I understand that certain procedures, such as dilation or the use of eye drops, may cause temporary discomfort, blurred vision, or light sensitivity. The risks and benefits of these procedures have been explained to me, and I will have the opportunity to ask questions.

Privacy and Confidentiality

I acknowledge that my personal and medical information will be kept confidential in accordance with HIPAA regulations and will only be shared with necessary healthcare professionals for the purposes of my treatment, billing, or healthcare operations.

Patient Rights

I understand that I have the right to:
- Be informed about my diagnosis, treatment options, and any potential risks
- Refuse or withdraw consent for treatment at any time
- Receive a second opinion if desired
Patient Consent
I certify that I have read and understand this informed consent form. I have had the opportunity to ask questions and consent to the optometric services described above.
Patient/Legal Guardian Name

First NameLast Name
Signature
Date

MonthDayYear
Date
Should be Empty:

Optometry Intake and Consent Form

Patient Information

Consent for Optometry Services

Patient Consent